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Journal of Hepato-biliary-pancreatic... Jan 2018The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute... (Review)
Review
The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1 edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
Topics: Acute Disease; Biliary Tract Surgical Procedures; Cholangitis; Cholecystitis, Acute; Female; Humans; Magnetic Resonance Imaging; Male; Multimodal Imaging; Practice Guidelines as Topic; Prognosis; Severity of Illness Index; Tokyo; Tomography, X-Ray Computed; Ultrasonography, Doppler, Color; Video Recording
PubMed: 29032636
DOI: 10.1002/jhbp.515 -
Journal of Hepato-biliary-pancreatic... Jan 2018The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If... (Review)
Review
The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
Topics: Acute Disease; Anti-Bacterial Agents; Cholangitis; Cholecystitis, Acute; Clinical Decision-Making; Drainage; Female; Follow-Up Studies; Humans; Male; Monitoring, Physiologic; Practice Guidelines as Topic; Risk Assessment; Severity of Illness Index; Software Design; Sphincterotomy, Endoscopic; Tokyo; Treatment Outcome
PubMed: 28941329
DOI: 10.1002/jhbp.509 -
Journal of Hepato-biliary-pancreatic... Jan 2018Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these... (Review)
Review
Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
Topics: Acute Disease; Anti-Bacterial Agents; Checklist; Cholangitis; Cholecystectomy; Cholecystitis, Acute; Conservative Treatment; Disease Management; Drainage; Female; Humans; Male; Practice Guidelines as Topic; Prognosis; Tokyo
PubMed: 29090868
DOI: 10.1002/jhbp.519 -
World Journal of Emergency Surgery :... Nov 2020Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new... (Review)
Review
BACKGROUND
Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.
MATERIALS AND METHODS
The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.
RESULTS
The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.
CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS
ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.
Topics: Cholecystectomy; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Drainage; Humans
PubMed: 33153472
DOI: 10.1186/s13017-020-00336-x -
Journal of Hepato-biliary-pancreatic... Jan 2018We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward... (Comparative Study)
Comparative Study Review
We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
Topics: Cholecystectomy; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Conversion to Open Surgery; Diagnostic Imaging; Disease Management; Drainage; Female; Humans; Male; Practice Guidelines as Topic; Severity of Illness Index; Software Design; Tokyo
PubMed: 29045062
DOI: 10.1002/jhbp.516 -
The Korean Journal of Gastroenterology... May 2018Acute cholecystitis is a common serious complication of gallstones. The reported mortality of acute cholecystitis is approximately 3%, but the rate increases with age or... (Review)
Review
Acute cholecystitis is a common serious complication of gallstones. The reported mortality of acute cholecystitis is approximately 3%, but the rate increases with age or comorbidity of the patient. If appropriate treatment is delayed, complications can develop as a consequence with a grave prognosis. The current standard of care in acute cholecystitis is an early laparoscopic cholecystectomy with the appropriate administration of fluid, electrolyte, and antibiotics. On the other hand, the severity of the disease and patient's operational risk must be considered. In those with high operational risks, gall bladder drainage can be performed as an alternative. Currently percutaneous and endoscopic drainage are available and show clinical success in most cases. After recovering from acute cholecystitis, the patients who have undergone drainage should be considered for cholecystectomy as a definitive treatment. However, in elderly patients or patients with significant comorbidity, operational risks may still be high, making cholecystectomy inappropriate. In these patients, gallstone removal using the percutaneous tract or endoscopy may be considered.
Topics: Anti-Bacterial Agents; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Drainage; Electrolytes; Gallbladder; Humans
PubMed: 29791985
DOI: 10.4166/kjg.2018.71.5.264 -
Journal of Hepato-biliary-pancreatic... Jan 2018In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo... (Review)
Review
In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
Topics: Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Female; Humans; Male; Patient Selection; Practice Guidelines as Topic; Prognosis; Risk Assessment; Severity of Illness Index; Tokyo; Treatment Outcome; Video Recording
PubMed: 29095575
DOI: 10.1002/jhbp.517 -
BMJ Clinical Evidence Aug 2014Of people admitted to hospital for biliary tract disease, 20% have acute cholecystitis. Up to the age of 50 years, acute calculous cholecystitis is three times more... (Review)
Review
INTRODUCTION
Of people admitted to hospital for biliary tract disease, 20% have acute cholecystitis. Up to the age of 50 years, acute calculous cholecystitis is three times more common in women than in men, and about one and a half times more common in women than in men thereafter. About 95% of people with acute cholecystitis have gallstones. Optimal therapy for acute cholecystitis, based on timing and severity of presentation, remains controversial.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute cholecystitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 18 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: early cholecystectomy, laparoscopic cholecystectomy, observation alone, open cholecystectomy, and percutaneous cholecystostomy.
Topics: Cholecystectomy; Cholecystitis, Acute; Gallstones; Humans
PubMed: 25144428
DOI: No ID Found -
International Journal of Surgery... Jun 2015Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC) in the treatment of acute cholecystitis (AC). Laparoscopic... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC) in the treatment of acute cholecystitis (AC). Laparoscopic cholecystectomy (LC) is now considered the gold standard of therapy for symptomatic cholelithiasis and chronic cholecystitis. However no definitive data on its use in AC has been published. CIAO and CIAOW studies demonstrated 48.7% of AC were still operated with the open technique. The aim of the present meta-analysis is to compare OC and LC in AC.
MATERIAL AND METHODS
A systematic-review with meta-analysis and meta-regression of trials comparing open vs. laparoscopic cholecystectomy in patients with AC was performed. Electronic searches were performed using Medline, Embase, PubMed, Cochrane Central Register of Controlled Trials (CCTR), Cochrane Database of Systematic Reviews (CDSR) and CINAHL.
RESULTS
Ten trials have been included with a total of 1248 patients: 677 in the LC and 697 into the OC groups. The post-operative morbidity rate was half with LC (OR = 0.46). The post-operative wound infection and pneumonia rates were reduced by LC (OR 0.54 and 0.51 respectively). The post-operative mortality rate was reduced by LC (OR = 0.2). The mean postoperative hospital stay was significantly shortened in the LC group (MD = -4.74 days). There were no significant differences in the bile leakage rate, intraoperative blood loss and operative times.
CONCLUSIONS
In acute cholecystitis, post-operative morbidity, mortality and hospital stay were reduced by laparoscopic cholecystectomy. Moreover pneumonia and wound infection rate were reduced by LC. Severe hemorrhage and bile leakage rates were not influenced by the technique. Cholecystectomy in acute cholecystitis should be attempted laparoscopically first.
Topics: Blood Loss, Surgical; Cholecystectomy; Cholecystitis, Acute; Humans; Laparoscopy; Length of Stay; Operative Time; Postoperative Complications
PubMed: 25958296
DOI: 10.1016/j.ijsu.2015.04.083 -
Cirugia Y Cirujanos 2021Acute calculous cholecystitis (AC) is one of the most frequent surgical emergencies in our field. Laparoscopic cholecystectomy is considered the treatment of choice,... (Observational Study)
Observational Study
BACKGROUND
Acute calculous cholecystitis (AC) is one of the most frequent surgical emergencies in our field. Laparoscopic cholecystectomy is considered the treatment of choice, although not sufficiently widespread.
OBJECTIVE
To analyze the application of the Tokyo Guidelines in the management of AC and to determine the influence of the degree of severity on management and prognosis.
METHOD
Prospective, observational study of patients with a primary diagnosis of AC between 2010 and 2015.. Exclusion criteria: AC recurrence; AC as a secondary diagnosis; acalculous cholecystitis; concurrent biliary pathology. Severity was classified according Tokyo 2013 Guidelines.
RESULTS
998 patients were included: 338 (33.9%) mild AC, 567 (56.8%) moderate AC, and 93 (9.3%) severe AC. A total of 582 (58.3%) patients were operated on. Postoperative complications Dindo-Clavien grade ≥ II 12.6%: mild AC 3.6%; moderate AC 12.2%; severe AC 49.0% (p < 0.001). Overall mortality 2%: mild AC 0%; moderate AC 0.5%; severe AC 18.0% (p < 0.001).
CONCLUSION
Urgent laparoscopic cholecystectomy remains the treatment of choice for mild and moderate AC. In patients with severe AC, the risks and benefits of surgery should be assessed, given the high degree of complications and associated mortality.
Topics: Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Humans; Length of Stay; Prospective Studies; Retrospective Studies; Tokyo; Treatment Outcome
PubMed: 33498065
DOI: 10.24875/CIRU.19001616